Prognostic determinants after hepatoportoenterostomy for biliary atresia

Optimal therapy for patients with biliary atresia: portoenterostomy ("Kasai" procedures) versus primary transplantation

As the results with liver transplantation have improved, a controversy has arisen regarding the precise role of a portoenterostomy in the treatment of infants with biliary atresia. The controversy centers around three issues: (1) the short- and long-term survival rates achieved with both procedures, (2) the influence of a portoenterostomy on a subsequent transplant, and (3) the shortage of suitable liver donors for very small infants. To address these questions, we retrospectively reviewed the charts of 48 children with biliary atresia who underwent liver transplantation and compared these results with 35 children transplanted for other liver diseases. As a group, the biliary atresia patients had significantly lower mean body weights and ages and spent a significantly longer time on the waiting list. In addition, significantly more of the biliary atresia patients had undergone prior abdominal surgery when compared with the non-biliary atresia group. There was no difference in the intraoperative variables of mean anesthesia time, mean operative time, mean anesthesia preparation time, nor the mean amount of blood transfused intraoperatively between the two groups. However, when the biliary atresia patients who had undergone a portoenterostomy with a stoma were compared with either the biliary atresia patients who did not have a stoma created as part of their portoenterostomy or the non-biliary atresia patients, significant differences were noted in mean total anesthesia time, mean operative time, and the mean amount of blood transfused intraoperatively. The survival rate of the biliary atresia patients was significantly greater than the non-biliary atresia patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Biliary atresia: early determination of prognosis

Analyses of bile bilirubin during the first month after Kasai operations, and of the liver biopsies obtained at the time of initial surgery, were done in 67 patients with biliary atresia. Bilirubin excretion (milligrams per day) was determined as the product of the bile volume and its concentration. Operative liver biopsies were evaluated for fibrosis, bile duct proliferation, bile stasis, giant cell transformation, and parenchymal degeneration; the severity of each abnormality was graded on a scale of 0 to 4. A forward stepwise regression procedure using the Cox proportional hazards model identified the relationship between survival and covariants. Thirty-nine of 67 patients died. Of these, 38 excreted less than 6 mg of bilirubin per day during the first postoperative month. The other patient died of a coexisting anomaly. Nine other patients who excreted less than 6 mg of bilirubin per day are alive but are either jaundiced or awaiting transplantation. Nineteen patients who excreted greater than or equal to 6 mg of bilirubin per day are alive (mean follow-up, 61 months) with normal or near-normal liver function. The severity of liver fibrosis, bile duct proliferation, and bile stasis did not correlate with survival, whereas giant cell transformation and parenchymal degeneration were highly significant (P less than or equal to .000 and P less than or equal to .0003, respectively). Twenty-six infants with grade 1-4 giant cell transformation or grade 2-4 parenchymal degeneration had a mean survival of 11 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Encouraging results with a modified Sawaguchi hepatoportoenterostomy for biliary atresia

Since 1974, 25 patients with biliary atresia underwent a modified Sawaguchi hepatoportoenterostomy. Seventeen of 18 patients operated on before the age of 10 weeks became free of jaundice within 2 to 4 months and had biliary intestinal continuity established by 10 months of age. Two of these patients experienced sudden diminution of bile flow with return of jaundice. Both responded to transconduit repeat resection of the portal fibrous tissue with resolution of jaundice, which allowed take-down of the biliostomy. At last follow-up 1 to 13 years postoperatively, all 17 patients were free of jaundice (94 percent of total). One patient in this group never had drainage of bile and eventually died from sepsis. In contrast, five of seven patients operated on after 10 weeks never had drainage of bile. Four of these patients died from hepatic failure and one from bleeding varices. Two patients initially had bile drainage and became anicteric, but thereafter, acute cessation of bile flow and reccurrence of jaundice occurred. Reoperation resulted in a definitive increase in bile flow in both of these patients. The modified Sawaguchi procedure is definitely preferable to liver transplantation as primary treatment in infants with biliary atresia, especially if operation is performed before the age of 10 weeks.

Recent experience with a modified Sawaguchi procedure for biliary atresia

The treatment of biliary atresia by variations of the original Kasai hepatoportoenterostomy has shown early success with good bile flow and the elimination of jaundice in 50% to 70% of cases in many series. Long-term follow-up in many of these patients shows continued problems with ascending cholangitis and progressive liver disease leading to death. Our recent experience with a modified Sawaguchi hepatoportoenterostomy is encouraging. Twelve patients were operated on before two months of age. All but one became jaundice free within 2 to 4 months and had biliary intestinal continuity reestablished within 3 to 6 months. These 11 patients have remained jaundice free with normal growth and development 1 to 8 years postoperatively. Two patients had one and two episodes of cholangitis, respectively. All have continued mild elevations of hepatocellular enzymes but no patient has obvious signs of liver failure. Serial liver biopsies have shown clearing of bile stasis and continued periportal fibrosis. Size and number of ductules in the excised biliary remnant did not correlate with clinical outcome. One patient remained jaundiced after hepatoportoenterostomy and reoperation, and eventually expired. In contrast, two patients operated at 4 and 9 months of age never drained bile and eventually died of bleeding varices and hepatic failure, respectively. The atypical success and relative lack of cholangitis in this series is not readily explained, but may be related to specific technical modifications of the original Sawaguchi procedure.

Analysis of patients with biliary atresia coming to liver transplantation

Seventy-two patients with end-stage liver disease underwent liver transplantation between March 1981 and March 1984; 35 (49%) with biliary atresia, the remainder with other disorders. This provided us with a unique opportunity to analyze factors leading to liver failure in patients who had undergone biliary drainage procedures for "uncorrectable" biliary atresia. Four patients in the biliary atresia group were excluded (no corrective procedure done, 3; "correctable" biliary atresia, 1), leaving 31 patients for study. Transplantation survival was 84% for the study group and 73% in children with other primary liver disorders. Most patients were less than 3 months old at the time of initial surgery, had minimal liver disease, and had accepted corrective operations by experienced surgeons. Despite these "favorable" factors, bile drainage was rarely achieved. All patients with continued bile drainage at the time of transplantation had repeated episodes of cholangitis, and cholangitis was associated with cessation of bile drainage in half of those with transient function. Findings at hepatectomy suggested that in four cases where bile drainage was never achieved, reexploration may have been successful. Complications included those associated with hepatic failure and portal hypertension. Of note were a high incidence of bone disease and a 43% incidence of stomal hemorrhage in patients with stomas. The short-term survival after transplantation was comparable in the biliary atresia group and the children with other disorders. This suggests that while the presence of a previous biliary drainage procedure may increase the technical difficulty of transplantation, it does not decrease survival.

Advances in treatment of biliary atresia

During 29 years from 1953 through 1981, 224 patients with congenital biliary atresia were treated and 200 of them underwent corrective operation at the Second Department of Surgery, Tohoku University Hospital. With the advance of surgical techniques and early diagnosis of biliary atresia, the rate of jaundice disappearance improved from the initial 15 per cent to the recent 69 per cent. Important factors contributing to the improvement of operative results included (1) an early operation, preferably within 60 days after birth, (2) a precise dissection and adequate transection of the porta hepatis, (3) prevention of post-operative cholangitis and (4) reoperation if indicated. Delayed operation and occurrence of post-operative cholangitis affected not only immediate but also long term operative results. Although, nearly all the patients with biliary atresia had portal hypertension at the time of surgery, the portal vein pressure decreased after successful operation, mainly due to improvement in portal venous circulation of the liver. It is considered from recent operative results that more than 80 per cent of patients with biliary atresia can be cured when an adequate corrective operation is carried out before 60 days of age and post-operative cholangitis is prevented.

Endoscopic recanalization of a portoenterostomy

Sudden cessation of bile flow occurred in an infant with biliary atresia following successful portoenterostomy. Bile flow was re-established by an endoscopic recanalization procedure, and has been sustained during 1 yr of follow-up.